Action Points

Note that this observational study found lower rates of use of CPR and AEDs in predominantly black neighborhoods.

There was no evidence of racial bias within neighborhoods, however, suggesting that issues regarding access and delivery to care are driving the disparity.

Almost two decades after researchers first reported big disparities in CPR delivery and cardiac arrest survival among blacks and whites, it appears that little progress has been made in closing the racial gap.

Published Aug. 30 in JAMA Cardiology, the study is among the first to examine differences of care and outcomes, including cardiac arrest bystander response and survival, by neighborhood. The findings suggest that the long recognized racial disparity in out-of-hospital cardiac arrest (OHCA) resuscitation care and outcomes persists.

But it also provides new evidence that OHCA location may largely explain this disparity.

Although CPR delivery and cardiac arrest outcomes were poorest in predominantly black neighborhoods and highest in predominately white ones, there appeared to be no racial bias within specific neighborhoods, lead researcher Monique Anderson Starks, MD, of Duke University Medical Center, told MedPage Today.

"Blacks and whites in predominantly black neighborhoods were equally less likely to survive than blacks and whites in predominantly white neighborhoods," she said. "This tells us that comprehensive system-of-care issues remain in predominantly black communities that need to be addressed, such as improving awareness of CPR."

The retrospective observational study included data from the Resuscitation Outcomes Consortium Cardiac Arrest Epidemiologic Registry on OHCA from 2008 through 2011. Census data were used to classify neighborhoods where OHCA occurred, based on percentage of black residents (less than 25%, 25% to 50%, 51% to 75%, or more than 75%).

Multilevel mixed-effects logistic regression modeling was used to examine the association between neighborhood racial composition and OHCA survival, adjusting for patient, neighborhood, and treatment characteristics.

The analysis included data on 22,816 adult patients with nontraumatic OHCA at Resuscitation Outcomes Consortium sites in the United States (median patient age, 64 years [interquartile range, 51-78].

Compared with patients whose OHCA occurred in neighborhoods with a lower proportion of black residents, those in neighborhoods with more than 75% black residents were slightly younger, were more frequently women, had lower rates of initial shockable rhythm, and less frequently experienced OHCA in a public location.

Among the main study findings:

The percentage of patients with OHCA receiving bystander cardiopulmonary resuscitation or a lay automatic external defibrillation was inversely associated with the percentage of black residents in neighborhoods.

A similar mortality risk for black and white patients with OHCA was observed in each neighborhood racial quartile.

When the primary model included geographic site, there was an attenuated nonsignificant association between racial composition in a neighborhood and survival.

Emergency medical services response times were shorter in predominately black neighborhoods, and Sparks said most EMS measures of care in predominantly black neighborhoods outperformed those seen in white neighborhoods. But there were troubling exceptions.

"In (predominantly black) communities it took longer for EMS to provide the first shock for shockable rhythms and codes were also called faster," she said.

EMS arrival-to-first defibrillation was significantly longer, and total time spent on resuscitation efforts was shorter for OHCA with shockable rhythms in neighborhoods with more than 75% black residents compared with neighborhoods with less than 25% black residents.

"If this is true, we need to find out why this is happening," Sparks said.

"Too little focus has been placed on reducing barriers to access across diverse communities," wrote Raina Merchant, MD, and Peter Groeneveld, MD, of the University of Pennsylvania in Philadelphia, in an editorial published with the study.

"Advancing the field of resuscitation science requires that research move beyond describing disparities for vulnerable populations and instead focus on implementing practices that reduce and/or eliminate disparities," they wrote. "Given the lack of progress in the last 20 years, creative efforts and novel interventions are imperative."

They noted that social media and new technologies may offer novel ways to speed reaction times when OHCA occurs. Specific examples include using mobile telephone connectivity to develop networks of potential CPR responders and using crowdsourcing to engage the public in locating, tagging, and reporting the locations of AEDs.

They even suggest that drones could potentially be used to deliver AEDs to OHCA sites.

"Efforts should target all aspects of the American Heart Association's Chain of Survival, while also harnessing the power of digitally connected health, including mobile telephones, social media, and drone technologies, to engage the public," they wrote. "These efforts will propel the field of resuscitation science from observation to intervention to the benefit of all communities."

Funding for this research was provided by the National Heart, Lung and Blood Institute, the National Institute of Neurological Disorders and Stroke, and others.

The researchers reported no relevant relationships with industry related to this study.

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